Wednesday, March 19, 2008

Upright birth in hospitals

I am taking the liberty of reposting some comments from doctorjen from my earlier post Get Off Your Back--References about how she facilitates upright and active births in a hospital environment, including when women have epidurals. I'd love to hear from other people who attend births in hospitals about how they make this possible.

It seems that there are two major factors important for making this happen in a hospital setting:
1) The hospital staff must have a strong commitment to active, upright labor.
2) The staff must also have first-hand experience facilitating this, especially for moms who have epidurals, IVs, fetal monitors, etc.

Okay, enough of me. Here's doctorjen:
I find that with some help it is possible to get almost all epidural moms upright. Most have enough sensation to support themselves on hands and knees. We put the back of the bed up most of the way so mom can drape her upper body over the top of the bed and then help them get their knees securely under them, and it usually works. They may need assistance to get in this position, but they usually can sustain once we get them up. Also, squatting is not too hard. My labor bed goes into a full chair position with the feet dropped all the way down. We then put the squat bar on the bottom of the bed. Mom can sit at the edge of the top of the bed between contractions and with help when a contraction starts and leaning on the squat bar, they can drop down into a squat to push. Some epidural moms have enough sensation to get themselves up and down and if not, they can use their arms for support and we just help them get up and down. Again, once they are in the squat they usually have enough sensation to support themselves. I have a policy of no operative vaginal delivery without trying a full squat first, and it almost always works. And very importantly, I try to let all epidural moms labor down as much as possible and not do any pushing until they have some urge and sensation. If we get to 2 hours of complete dilation with no sensation yet, we negotiate about turning it off and then most moms eventually get an urge to push.

I find it much harder to move a mom with an epidural around, and they don't tend to be changing positions frequently like a mom laboring spontaneously without anesthesia, but it's both possible to do it and helpful. My nurses were way skeptical at first, but after seeing a few babies come sailing out quickly in a squat they are all big believers now and will be telling me to get mama up if I haven't for some reason thought of it! The hardest part is moving all the wires we have going with an epidural --external fetal monitor, external contraction monitor, urinary catheter, IV, epidural line, and blood pressure cuff. We have it down to a science now, though--we unplug everything that unplugs, pull all wires to one side, flip or move the mama, and replug everything in, passing them under the mama's belly if we've moved to hands and knees. I enforce with my labor clients and my nurses that the mama's comfort is our number one concern and the monitors are our job to keep track of. So mama moves as she needs to, and we chase the cords....

Thought you might like to hear about a nice upright birth I attended an hour and a half ago. Second baby, spontaneous labor at 40 weeks 4 days, no augmentation, no IV, no AROM, just labor. Mama did a lot of laboring in bed because she was tired, but at the very end of labor, she got up. She had been grunting a bit with contractions, but not really pushing, and she thought she needed to pee. We went to the bathroom, but she wasn't able to get comfortable and wasn't able to go. She hopped up and down from the toilet several times, and then squatted on the floor holding on to the sink for a bit. Finally, she said "forget it" and we headed back into the labor room. At this point, she stopped at the end of the bed and squatted down on the floor holding on to the end of the bed. This felt good to her, so we spread some pads on the floor, and over the next few contractions she would go from kneeling to squatting, to kneeling on one knee, to hands and knees. Suddenly, her water broke with a huge gush. Then she decided to try the bathroom again and we went back in the bathroom, but again, a lot of up and down but not able to go. She decided to head back into the labor room, but then she knelt back down on the floor in the door of the bathroom suddenly and pushed all out with a contraction, and gave me that wide eyed "baby's coming" look. I asked her if she was comfortable there in the doorway, and she didn't answer but got up and headed back towards her pile of bed pads on the floor and knelt back down. Over the next 3 contractions she knelt, squatted, leaned back on her hands and feet (like a crab walk position almost!) and then back to squatting, sometimes holding the edge of the bed for support with both hands, sometimes with one hand, sometimes with her hands on the floor.

Finally, she pushed out the baby's head in a squat but almost sitting over one leg, so that leg was flexed and the other one a little extended, and then for baby's big, tight-fitting shoulders, she first knelt, then leaned back on her hands and lifted her hips in the air and the little linebacker finally slid out. The dad then sat down on the floor behind the mom and we slid a dry bit of pad under her and she sat down on the floor, leaned back into her partner's lap, and snuggled her baby on her tummy. The thing that always impresses me about a spontaneous second stage in an upright mother is that it's not a matter of getting in one position and pushing the baby out, but most mamas move frequently including during contractions. In the 3 long pushing contractions she had, she probably changed position 15 times--and with that baby's kind of sticky shoulders, I'm glad she was freely mobile and able to wiggle all over and push him out! That, in my experience, is what a true upright birth looks like! Most docs, though, would be driven nuts by having the baby be such a moving target (of course he was never more than a couple inches from the floor and could have easily just slid onto the pads on the floor) and having to get on the floor themselves. Luckily, I'm young and healthy and can kneel or squat myself pretty well, and fortunately tonight I didn't have one of the 2 currently 3rd trimester pregnant nurses trying to get down there with me.

Anyway, that's what an upright birth can look like in the hospital - even with a doctor.


  1. Thank you DrJen for one, putting your laboring mothers first and two for raising the awareness that getting off of your back is possible, even with an epidural! I had no idea.

    And thanks to Rixa for expanding on this important topic.

  2. When you said that an upright position requires the hospital attendants cooperation, that is an understatement. Epidural or not, most hospital personnel (including CNMs) would not dream of sacrificing their precious view.

  3. I not only work as a L&D RN, but am a CNM student and I teach labor support to all of the nurses in our single room maternity care unit. It's very frustrating for us because we put our patients in upright positions and then the docs come in and tell us to lay them down (if I could only convince them to take my classes!)
    There are a couple of docs who are on board with upright but unfortunately they are few. It's good to see a doc who supports it, just tell all your cohorts!!

    As far as upright pushing with epidurals you have to be careful about how long they stay upright and by this I mean truly upright, as in squatting, taylor sitting or sitting upright. Because these are getting large volumes of IV fluids for epidurals if they have been upright for a while >30 min you will see their labia and perineums really start to swell, this is basically just dependent edema from the fluids given for epidurals. This swelling can cause more severe perineal tears.

    Great topic and I really enjoy your blog!

  4. Thanks for this post! Even having attended births at home and in a birth center, I've only seen an upright position for birth once, in a hospital, with a family doc catching! And all of my clients express a desire prenatally not to push on their backs but one has even been told by the nurses that the baby won't be able to get past the pelvis if she's not laying down. But I'm just a doula, who am I to say otherwise :)

  5. Laura--so in all of your births, you've only seen one upright one, total? Wow, I'm trying to wrap my mind around that. I've only seen one non-upright birth, and it was in a hospital birth where mom had an epidural (well, there was also one home birth where she did side-lying at the very end after her midwife urged her to get out of the tub). Granted, I've only been to three hospital births as a doula so I am sure I would have seen more reclining positions if I had continued attending births.

  6. Kudos to you, Dr. Jen. You are helping to shift the tide of our birthing culture by giving freedom, space, love, and support to birthing moms. Thank you for sharing these tips and experiences with us!
    Now, come on and move down to Phoenix to bring this kind of hospital sacred birthing experience to us...:)

  7. That was an amazing post. Even in Portland, Oregon, which is a pretty progressive birthing town (3 birth centers, lost of CNMs and CPMs, and 3 area in-hospital waterbirth centers) I have never seen anything like that. I have attended about 40 hospital births as a doula and I have only ever seen one upright pushing scenario where mom had an epidural. and that situation ended in the OR. Dr. Jen, you are amazing. I would love to see you teaching!

  8. I had assumed upright births in hospitals were rare-- not sure if the nurses were sure how to set up the birthing bar but they did finally! I was up in a squat for my entire pushing phase, but the ultimate contraction/push was supine (hospital). My birth a few months ago was in a birth center and I delivered her head sqautting and her body standing. Both kids popped right out... 10 lbs., 3 oz. and 11 lbs., 5 oz.

    Good to know that I can pass on to friends that upright birth is a possibility with an epidural, too. Could probably save a lot of moms from c-sections. Thanks.

  9. I had the help of an l&d nurse, my husband, and my mom to get into a squat, on the bed, with a shut-off epidural for my first birth. He was badly malpositioned, and I think it was the only thing that helped me give birth vaginally. My legs were still almost completely numb, so they held me up. I wasn't a light weight at the end of that pregnancy, either! ;)It was the nurses idea. I wish I knew who she was so I could send her flowers every year on his birthday!

  10. Oh, forgot to mention that he was crowned and born supine.

  11. Many nurses do hands and knees pushing with epidurals. I do it with most of my patients. HOwever, they do not deliver that way.

    I once had a woman deliver the baby while upright without an epidural. The problem was, she started bleeding excessively and it was very hard to get her to move onto her back during her postpartum hemorrhage. I had a hard time convincing her this was an emergency and we needed her to move...Please...

  12. I cant even imagine this. Dr Jen you are a rare rare sensible creature and I worship you.

    I have never heard of or seen any woman being "allowed" to do anything at all once hooked up, not even lay on her side. I hope to be wiggling and moving my own baby out in hospital this June, cant picture otherwise, but also cant picture it being "allowed" either. Will discuss with Dr. and midwife next visit. wonderful to hear some normalcy and some common sense being brought to the hospital wards.

  13. 'Just before I was ready to push out my second baby, I went to lay down on my back, which was how I gave birth the first time. My midwife, however, did that nice midwife-y talking and somehow convinced me to actually hoist myself onto my knees and lean against a chair. So I did.

    A few minutes (hours? Who knows during labor ....) my second daughter slithered on out. Four words: huge baby, no tearing.

    For that reason alone I'm a convert to birthing upright, what apparently is called in the biz "vertical birth." '



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